While we may strive to create and manage the most comprehensive and "pristine" CDI program ever, practical considerations dictate a different reality for us. Budgets, cooperation, support, and multiple priorities are just a few of the practical considerations that we need to consider when defining program goals for a year, a quarter, or even a month. As with many other functions in healthcare, priorities are often a trickle-down effect from the Federal government. As the payor for almost 60 percent of hospital care and almost 63 percent of outpatient care, the priorities of the Federal government (AKA CMS) commands our attention.
The Recovery Audit Contractors (RAC) program is one of those priorities because it may mean a pay-back of hundreds of thousands of dollars. One presentation estimates the average payback per hospital at just above a half million dollars. In many ways, however, the RAC program is no different than any other government recovery program. In fact, we could safely say that the RACs are to the beginning of the 21st Century what the OIG audits were to the end of the 20th century. As a result, you can also apply many, but not all, of your OIG strategies to effectively combat this enemy. What are they?
1. First, know that, according to CMS, the RACs are using their own proprietary software to identify cases for both automated as well as complex review. Knowing this, you can run your own algorithms to identify any problematic trends. Most hospitals have programs in place for OIG issues, this is no different. It's just that the OIG is on to "bigger and better" things.
2. If you don't have your own computerized program, use the list of suspect DRGs that are published on the RACs website. In fact, if you are not already using your RACs website as a resource to guide your activities, you probably want to look into this.
3. Know that everything and anything may matter when it comes time to appeal a RAC determination. This is especially the case if you partner with a good solid outside party to represent you. For hospitals with hundreds of thousands of dollars in payback, the right partner to assist you with the appeals process is key.
4. Effective education and training is also key. From the CDI perspective, educating physicians on appropriate documentation practices on an ongoing basis and maintaining documentation of who was trained and what the results of that documentation were is just as important as the training itself. This is where online training for physicians who have taken post-tests after the training can be key to proving certain arguments you and your appeal representative may want to make. Like HIPAA training, if you haven't already thought about online CDI training, now may be the time to do that.
5. The other OIG strategies that most hospitals should still have in place (in addition to education and training) include keeping written, updated policies and procedures - in this case for documentation, CDI activities, querying, and coding. Lastly, regular internal monitoring and auditing (often external auditing) of CDI is key to keeping the program on track and ensuring no future RAC violations.....
6. Remember, all of the activities described in #4. & #5. can often be admitted as evidence of mitigation for past and current claims as well.
